Professional Documents
Culture Documents
Group 2A (2014)
Schizophrenia
Define as major mental disorder
characterized by disturbance of :
i. Thinking
ii. Emotion
iii. Behaviour
. Often accompanied by deterioration
in personality and functioning
Epidemiology
Worldwide (WHO)
affecting about 7/1000 of the adult
population
affects about 24 million people
wordwide
mostly in the age group 15-35 years.
the incidence is low (3-10,000) but
the prevalence is high due to
chronicity.
Malaysia
National Mental Health Registry
report that 7351 cases had been
registered from 2003 to 2005.
the median incidence rate was 15.2
per 100,000 (range of 7.7 to 43.0
per 100,000
The incidence was noted higher in
males, urban and migrant
population.
Findings of Malaysia
National Mental Health
Registry Report
d. Body weight
e. Duration of Untreated Psychosis
(DUP)
f. Family history
A total of 21.6% had family history of
mental illness, 20% had some
form of co-morbidity,
g. co-morbid conditions (substance
abuse)
h. Medical co-occuring conditions
Diabetes mellitus and hypertension
Predisposing Factors
Genetic
Those with family history of schizophrenia
Parents 6%
Siblings 9%
Children 13%
Dizygotic twin 17%
Children with two affected parents 46%
Monozygotic twin 48%
Social
Cannabis abusers
Individual living in higher level of
urbanisation (1.40-fold increased risk)
Environment
Those with history of childhood
central nervous system infection.
history of obstetric complications
Dopamine Hypothesis
DOPAMINE HYPOTHESIS
The Dopamine hypothesis states that
the brain of schizophrenic patients
produces more dopamine than normal
brains.
Evidence comes from
studies with drugs
post mortems
pet scans
Normal Level of
Dopamine In The
Human Brain
Elevated Level of
Dopamine In The Brain of
a Schizophrenic Patient
(specifically the D2
receptor)
ROLE OF DRUGS
Amphetamines (agonists) lead to increase in
DA levels
Large quantities lead to delusions and
hallucinations
If drugs are given to schizophrenic patients
their symptoms get worse
Parkinsons disease
Parkinsons sufferers have low
levels of dopamine
L-dopa raises DA activity
People with Parkinson's develop
schizophrenic symptoms if they
take too much L-dopa
POST MORTEM
Falkai et al 1988
Autopsies have found that people with
schizophrenia have a larger than usual
number of dopamine receptors.
Increase of DA in brain structures and
receptor density (left amygdala and
caudate nucleus putamen)
Concluded that DA production is abnormal
for schizophrenia
POSITIVE SYMPTOMS
Delusions
Hallucinations
Disorganised speech/thinking (thought disorder or
loosening of
associations)
Grossly disorganised behaviour
Catatonic behaviours
Other symptoms:
Affect inappropriate to the situation or stimuli
Unusual motor behaviour (e.g. pacing and rocking)
Depersonalisation
Derealisation
Somatic preoccupations
These tend to respond more robustly to the current
antipsychotic medications
NEGATIVE SYMPTOMS
The symptoms that appear to reflect a diminution or
loss of normal
emotional and psychological function which includes:
i. Flat affect
the reduction in the range and intensity of emotional
expression:
facial expression, voice tone, eye contact, and body
language
ii. Alogia or poverty of speech
the lessening of speech fluency and productivity,
thought to reflect slowing or blocked thoughts, and
often manifested as short, empty replies to questions
iii. Avolition
psychological state characterized by general lack of
drive, or motivation to pursue meaningful goals.
e.g. no longer interested in going out and meeting with
friends, no longer interested in activities that the person
used to show enthusiasm for, no longer interested in
much of anything, sitting in the house for many hours a
day doing nothing
iv. Anhedonia
inability to experience pleasure from activities usually
found enjoyable
v. Attention (poor)
Negative symptoms are less obvious and often persist
even after the
resolution of positive symptoms.
COGNITIVE SYMPTOMS
Cognitive symptoms refer to the difficulties with
concentration and memory
i.e.:
Disorganised thinking
Slow thinking
Difficulty understanding
Poor concentration
Poor memory
Difficulty expressing thoughts
Difficulty integrating thoughts, feelings and behaviour
These symptoms may
performance
Three Phase:
Symptoms of schizophrenia usually present in three phases:
1. Prodromal
. Decline in functioning that precedes the first psychotic episode
. The patient may become socially withdrawn and irritable
. He or she may have physical complaints and/or newfound
interest in religion or the occult
2. Psychotic
. Perceptual disturbances, delusions, and disordered thought
process/content
3. Residual
. occurs between episodes of psychosis
. It is marked by flat affect, social withdrawal, and odd thinking
or behaviour (negative symptoms)
. Patient can continue to have hallucinations even with
treatment
Diagnosis of Schizophrenia
DSM-V Criteria
Two or more of the following must be present for at least 1
month:
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g Frequent derailment or
incoherence)
4. Grossly disorganized or catatonic behaviour
5. Negative symptoms (e.g Diminished emotional expression
or avolition)
- One of the two symptomsmustbedelusions,hallucinations,
ordisorganized speech.
. Level of functioning is markedly below the level achieved
prior to the onset.
. Duration of illness for at least 6 months which is well
distinguished from schizophreniform disorder.
. Symptoms not due to medical, neurological or substanceinduced disorder
Schizophrenia Subtypes
Paranoid type
Highest functioning type, older age of
onset. Must meet the following criteria:
Preoccupation with one or more delusions
(persecutory/grandeur) or frequent auditory
hallucinations (single theme, persecutory)
No predominance of disorganized speech,
disorganized or catatonic behavior, or
inappropriate affect
They are typically guarded, tense, reserve
and sometimes hostile. Intelligence remain
intact
Disorganized type
(Hebephrenia)
Poor functioning type, early onset.
Must meet the following criteria:
Disorganized speech (loosening of
association )
Disorganized behavior
Flat or inappropriate affect
Catatonic Type
Rare. Must meet at least two of
the following criteria:
Motor immobility
Excessive purposeless motor activity
Extreme negativism or mutism
Peculiar voluntary movements or
posturing (may hold awkward
position for a long time)
Undifferentiated Type
Characteristic of more than one
subtype or none of the subtypes
Prominent delusion
Hallucination
Incoherence
Grossly disturbed behavior
Residual Type
Prominent negative symptoms
(such as flattened affect or social
withdrawal)
Minimal evidence of positive
symptoms (such as hallucinations or
delusions)
Schizophreniform disorder
Episode lasts for 1-6m or <6m
Schizoaffective disorder
(Major Depressive episode/Manic
episode/Mixed Episode)+ Psychotic
symptoms (Criteria A)
Brief Psychotic Disorder
Disturbance <1m but >1d
Management
Management of schizophrenia
may be divided into following
phase :
1) Prodromal phase
-Impairments in psychosocial functioning, odd and eccentric behaviour, poor communication and motivation,
blunted or flattened affect and neglect of personal hygiene.
-No treatment
2) Acute phase
-Positive symptoms appear
-With adequate treatment, the symptoms will disappear in most patients.
-However, negative symptoms may persists
3) Relapse prevention
4) Stable phase
- After 10 years, patient become more stable with sign of improvement
Pharmacological treatment
Anti- psychotics are the mainstay of
pharmacological treatment in schizophrenia
These medications treat the symptoms of
disorder and do not cure shcizophrenia
The anti- psychotic drugs include two major
classes:
i) dopamine receptor antagonists.
ii) Serotonin- dopamine antagonists (SDA)
All APs are different in their efficacy and side
effects
Dopamine receptor
antagonists
Effective in treatment of positive symptoms
of schizophrenia
Cause extrapyramidal side effects such as
parkinsonism and hyperprolactinaemia.
Eg: haloperidol (haldol), chlorpromazine
(thorazine), perphenazine, sulpride,
trifluoperazine, fluphenazine,
zuclopenthixol, flupenthixol
Serotonindopamine antagonists
(SDA)
Known as atypical antipsychotic drugs
Effective against negative symptoms
Fewer neurological and endocrinological side effects.
But causing metabolic syndrome (weight gain,
dyslipidemia, and glucose intolerance)
Eg: clozapine, risperidone (risperdal), olanzapine,
quetiapine, ziprasidone, aripriprazole, paliperidone,
amisulpride
Psychosocial therapies
Objectives:
o Enable persons who are severely ill to develop social and
vocational skills for independent living
o To improve individuals ability to handle stressful life events
o Increase adherence to medications
o Promote better communication and coping skills
o Enhance quality of life
o Promote recovery
Prognosis
Several studies have shown that:o over 5 to 10 years period after first
psychiatric hospitalization for
schizophrenia, approximately only 10 to 20
% patients have a good outcome.
o >50% patients having poor outcomes,
repeated hospitalization, exacerbations of
symptoms, episodes of major mood
disorders and suicide attempts.
Insidious onset
Long 1st episode
Previous psychiatric history
Negative symptoms
Younger age at onset
Male
Single, separated, widowed or
divorced
Poor psychosexual adjustment
Poor employment
Social isolation
Poor compliance